Hello, everyone. I am Dr. Andrew Saxon. On behalf of the American Psychiatric Association, welcome to today's webinar, Treating Hepatitis C Among People Who Use Drugs. Today's activity is presented on behalf of the SAMHSA-funded Providers Clinical Support System, a program operated collaboratively by 19 medical specialty organizations, including the APA. Please note that following today's presentation, you will receive a follow-up email from PCSS within one hour of the webinar. This email will contain the instructions to claim credit for attending. Continuing education will be available for physicians, nurses, physician assistants, social workers, and pharmacists. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. We'll reserve 10 to 15 minutes, if we have it, at the end of the presentation for Q&A. Please feel free to submit your questions throughout the presentation by typing them into the questionnaire found in the lower portion of your control panel. Now I would like to introduce you to the faculty for today's webinar, Dr. Judith Suey. It gives me particular pleasure to introduce Dr. Suey, since she and I work together at the University of Washington, and we've been able to collaborate on a lot of worthwhile educational and research projects. Dr. Suey is an Associate Professor of Medicine at the University of Washington, based at both Harborview Medical Center and Evergreen Treatment Services. As a clinician investigator, Dr. Suey's goal is to improve care delivery and health outcomes for persons who use drugs who are at risk for HIV and hepatitis C virus. Dr. Suey's current research is focused on innovative health service delivery interventions to expand access and improve adherence to potentially life-saving medications for at-risk populations. I welcome you to today's session. Dr. Suey, thank you for leading today's webinar, and please take it away. Thank you, Dr. Saxon, for that introduction. It's a pleasure to be here today to talk about a topic that I'm very passionate about. A little bit more information about me. I'm an addiction medicine-trained physician from an internal medicine and primary care background. My clinical work has always been focused on persons who use substances. I started out treating hepatitis C in the early days in 2003 and quickly realized that hepatitis C was a disease that was born out of substance use disorders and wanted to address its root causes. So I became a buprenorphine waiver prescriber around 2008 and certified through the American Board of Addiction Medicine in 2013. So I now primarily do research at the University of Washington where I'm based at Harborview Medical Center, and it's such that you'll see that a number of the examples in my talk today are from Washington State, my home state. Next slide. I don't have any financial conflicts to disclose. Next slide. And the target audience for this talk today, the overarching goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders and related conditions, particularly in prescribing medications, as well for the prevention and treatment of substance use disorders. So these are the objectives for today's talk. By the end of the session, participants should be able to, number one, explain hepatitis C elimination campaigns and the importance of extending access to treatment for people who use drugs. Number two, to understand barriers and challenges to hepatitis C care, which are specific to people who use drugs, as well as ways to overcome. Number three, you should be able to use hepatitis C screening methods and understand options for treatment if a patient has hepatitis C. And number four, work with healthcare teams to initiate direct acting antivirals or DEAs with clients and know the key steps in treatment. But I will say that for me, the underlying goal of this talk is really to get providers like you excited and motivated to get patients who use drugs treatment for hepatitis C. So the intended audience for this talk today are clinicians and providers who are on the front lines for caring for persons who use drugs who are at risk for hepatitis C. And this includes physicians, physician assistants, nurses, pharmacists, social workers, counselors, and peer support specialists. And really this talk is a basic overview and hopefully can be accessible to all. Next slide. I'll start with a brief background on hepatitis C. Hepatitis C is an RNA virus that was first identified in 1988 when initially it was called non-A and non-B hepatitis. Unfortunately, unlike hepatitis A and B, it is not vaccine preventable. Most individuals who are exposed to hepatitis C around three quarters will develop a chronic infection and as such, it is the most common chronic blood-borne infection in the U.S. Next slide. In the U.S., it is estimated that around 2.4 million persons have been infected with hepatitis C. And unfortunately, around one half of individuals may not be aware of their infection. In the U.S., deaths from hepatitis C outnumber those from HIV and 60 other infectious conditions combined. Despite the fact that hepatitis C comprises a large portion of morbidity and mortality, there's a relatively modest amount of resources directed to hepatitis C from a federal level compared to HIV. Next slide. And this may in part be related to the fact that in the United States, hepatitis C is a disease that is driven by one of the most stigmatized conditions, that of injecting drugs. All the risk factors for hepatitis C are listed here, but the overwhelming majority of cases are attributable to injecting drugs. Of note for this audience, it is important to know that hepatitis C can be transmitted through the sharing of any injecting equipment. So that includes both needles and syringes, as well as cookers, cottons, and rinses. Also to note is that personal items that come in contact with blood can also transmit virus, such as razors, toothbrushes, and straws that are used for intranasal cocaine use. So it is important to counsel patients with hepatitis C not to share such items, in addition to not sharing any injecting equipment. Next slide. New hepatitis C infections have been increasing in the United States over the past decade, and this is intrinsically tied to the opioid crisis and a rise in injecting drugs. As you can see from this figure, there's been a fairly dramatic increase in new acute cases of hepatitis C over the past decade. And I'd like to point out the highest rate has been among young adults ages 20 to 40. Next slide. So while the previous slide showed you acute cases over time, I want to point out that acute cases generally represent only the tip of the iceberg for hepatitis C infections. Acute cases generally only come to attention when patients are symptomatic and seek medical care. But as you may know, generally, most acute cases of hepatitis C are asymptomatic. So patients do not have symptoms or have very mild symptoms. So really, those numbers are just the tip of the iceberg. Next slide. So the rise in cases in young adults has had a dramatic impact on disease distribution in the population for hepatitis C. So this slide shows data from Washington State, but a similar pattern has been reported among states around the country and reflects a national trend towards an increase in cases among young adults that has shifted the prevalence of disease in age groups. So whereas before, there was a normal distribution of prevalence around middle-aged adults or baby boomers in 2007, in 2018, as you can see, there was a shift towards a bimodal distribution where a nearly equally high prevalence of hepatitis C was seen among young adults and the baby boomer generation. Another thing to mention is that in addition to cases rising in young adults, they've also increased dramatically in rural areas where the opioid epidemic has been hard hit, which poses further challenges since treating providers for hepatitis C are often in short supply in those communities. Next slide. So what are the risks of untreated hepatitis C infection? The primary concern is that individuals will over time develop liver disease. It is estimated that of those with chronic infection, 15 to 30% will develop cirrhosis, which can lead to liver cancer at a rate of 3 to 5% per year, as well as risk for liver failure and death. And it's also important to point out that the risk of developing these complications greatly increases with the use of alcohol. Next slide. But aside from the risks of downstream liver effects, it is also important to acknowledge that hepatitis C is a chronic viral infection accompanied by sustained inflammatory responses that can potentially impact many different organ systems, including the kidneys, heart, and brain. The figure on the left summarizes some of these extra hepatic effects, which can include diabetes, thyroid disease, arthritis, and glomerular kidney disease. Also, the experience of living with hepatitis C is a highly stigmatized condition, and that can contribute to chronic stress. And patients frequently report fatigue, sleep problems, depression, and anxiety. Next slide. So although the primary reason to treat hepatitis C is to reduce liver complications, there are many other secondary benefits to treating hepatitis C, as demonstrated in this slide. Particularly relevant for treating people who use drugs are the benefits that are up in the right-hand corner, the positive psychosocial effects and improved quality of life, as well as the public health benefits of reduced transmission to other individuals. Next slide. Quantitative and qualitative studies have shown there are many psychological benefits of treating patients for hepatitis C. Studies have demonstrated improvements in health-related quality of life using scales such as the SF-36. And research has demonstrated positive effects on self-efficacy and empowerment, which in turn can translate to reductions in substance use. For many patients, their hepatitis C infection is a constant reminder of prior behaviors that they would like to shed baggage from their years of drug use. So getting cured of hepatitis C can be a highly transformative event for some patients. Here are some illustrative quotes from qualitative studies that I particularly like. Clearing hepatitis C will help in defeating the bigger problems because it's like trying to get up when you've got a hundred bricks on you. But then if I took half the bricks off from hepatitis C, then I've got a bit more movement and I can start taking the bricks off. Everything changed. I stopped drug use. I stopped everything because I said, if I beat the hep C, I could beat that too. Praise God, up to today, I feel so good. Next slide. So the other important benefit of treating and curing hepatitis C among persons who use drugs is the reduction in risk of transmission. Think about it. If treatment is restricted to persons who abstain from using drugs, as has been the case historically, there will be little progress made to prevent new infections. In order to reduce the spread of disease and the rate of new cases, i.e. incidents, we must treat and cure the individuals who are transmitting, namely those individuals who are actively using or specifically injecting drugs. This is a concept called treatment as prevention, and it's something that we've seen proof of concept for HIV, and evidence is starting to emerge for hepatitis C. Next slide. So current guidelines recommend treating all persons with hepatitis C regardless of substance use. In fact, the guidelines call out the fact that treating people who use drugs is critical for achieving hepatitis C elimination goals. So the guidelines shown here come from the leading ID, infectious disease and hepatology professional societies in the U.S., and are available on the website, hcbguidelines.org. And basically, again, treatment is indicated for all individuals except for those with a very short lifespan that cannot be remediated with treatment. And in the case of a shortened lifespan from disease related to hepatitis C, they should, of course, be treated, but through specialists. Next slide. Yet, in the real world, there's still a lot of resistance to treating persons who are actively injecting and using drugs. And this may be in part due to some of the beliefs that are listed here. The first one is that people who use substances can't be effectively treated and cured. And the second is that people who use substances are just likely to get reinfected anyway. Though previously assumed to be true and incorporated into guidelines and medication coverage requirements, these assumptions have largely been disproved with research. Next slide. So before I delve into some of the studies, I do want to review the definition of cure. So hepatitis C cure, also known as sustained virologic response, or SVR, is defined as having no detectable hepatitis C virus 12 or more weeks after the completion of treatment. And in this talk, DEAs will also refer to direct acting antiviral medication. Next slide. So getting back to myth number one, that people who use substances can't be cured. Well, studies from various settings have shown good adherence and high cure rates among people who use drugs, including those who inject drugs. And there are no data to support pretreatment screening for illicit drug or alcohol use to select a population more likely to be successful with hepatitis C treatment or to impose criteria for abstinence. Next slide. So this is a somewhat busy slide that summarizes results from four key studies that have looked at SVR or cure rates for persons with substance use. The evidence that comes from these studies shows that people who use drugs may achieve cure rates that are nearly equivalent to persons who are not actively using drugs. Some of those who start medication upwards of 90% achieve SVR. Furthermore, I'd like to point to the last study, which was recently published in 2020. That study looked at adherence to the use of electronic blister pill packs. And that study found that patients had excellent cure rates, even those who had suboptimal adherence. So, in fact, they found that for those patients who took more than 50% of their medications, nearly everyone was cured. This speaks to the fact that the DAs are highly efficacious and quite forgiving of imperfect adherence. So, for the second myth, that people who use drugs will just get reinfected. In fact, the literature suggests that rates of reinfection among people who use drugs is low and substantially lower than the rates of first-time infection. And this is likely because patients moderate their behaviors. Indeed, hepatitis C treatment has been associated with reduced opioid injecting and sharing. Next slide. So, this slide shows data from a recent meta-analysis that was published in 2020 that looked at rates of new infections after cure. As you can see, the incidence of reinfection is quite low, ranging from four to six cases per 100 person-years. And the lowest rates were seen for persons who were on opioid agonist therapy. So far from being the case that all patients will be reinfected, the data suggests it will be a small minority. And furthermore, reinfection will be less likely if more individuals who are transmitting are cured, bringing down the community viral load, something that is achievable only if we make major efforts to treat and cure as many active people who inject drugs as quickly as possible. Like to point out also that those rates of reinfection can be prevented through the use of opioid agonist treatment, so medications like buprenorphine and methadone. Next slide. So, hepatitis C elimination has been declared an achievable goal, and now there's a global call for elimination. In 2016, the WHO announced a plan for eliminating hepatitis C by 2030. However, according to recent research, many high-income countries are not expected to achieve elimination before 2050, including the US. Currently, there are only three states that are projected to succeed in eliminating hepatitis C by 2030, and I'm glad to say that also that includes my home state of Washington. And why is that? Well, for one thing, there is a statewide plan for hepatitis C elimination. In 2018, Governor Inslee announced the Hep C Free Washington Initiative. As part of that initiative, people who inject drugs were identified as a priority population for treatment, and there was a lifting of provider restrictions that was in part made possible by the Washington Health Care Authority's success in negotiating a contract with AbbVie that made it possible to extend treatment to all Washingtonians with hepatitis C. Next slide. So there has been a shift in policy, which now aligns with the expert guidance, which includes the following. No requirements for abstinence. No requirements for evidence of fibrosis. In Washington state, any licensed prescriber can treat hepatitis C, and that includes primary care providers. It's not necessary to document chronic infection with multiple consecutive tests. A single detectable RNA is sufficient. And prior authorization is not needed for the primary medication that is recommended, which is GP. So Washington state is on the leading edge of lowering barriers to hepatitis C treatment, but I would say that there are many, most states are following in suit. Next slide. But have those policy changes translated to more people who inject drugs getting treated and cured? Unfortunately, the answer is not as quickly as we would like, particularly for certain groups. So this slide shows data from a study that I participated in out of UW that used local CDC data from NHBS, which is a CDC survey, which every three years focuses on people who inject drugs. So this study used data from 2018, so about five years since the first EAA came out. So this study looked at individuals who were screened and found to be positive through the study itself. And of those individuals, the majority had been tested before for hepatitis C and majority even knew their diagnosis, were aware. And yet it was the small minority only of those who were aware of their infection who had received treatment. The study also looked at subgroups and found that women, younger adults, and homeless individuals had even lower rates of treatment, suggesting emerging disparities. So there's really an urgent need to offer treatment for people who inject drugs in settings where they are seen. Next slide. And we urgently need more treatment providers and providers who are on the front lines of taking care of persons who use drugs to provide hepatitis C treatment. So you might wonder, are low rates of treatment related to a lack of interest among people who inject drugs? This study was conducted using data from a state syringe exchange survey from Washington State in 2019. And from that study, it was shown that the majority of people who inject drugs, 68%, did have an interest in hepatitis C treatment. Next slide. So the big picture of hepatitis C treatment is that treatment is now quite straightforward due to DAs and can be done by non-specialists, including primary care physicians, nurses, physician assistants, and even pharmacists. So studies have, in fact, demonstrated equivalent and sometimes better cure rates among primary care providers and advanced practice providers compared to specialist providers. In people with advanced liver disease or certain other conditions, such as transplant or liver cancer, treatment is more complicated and should be done by or in consultation with specialists. Next slide. So now let's dive into the specifics of treatment a bit. And just a heads up that I have about 10 to 12 slides covering the basics of treatment. And at the end of this session, I have a list of resources that you will want to take advantage of to provide support if and when you start treating patients. So direct acting antivirals or DAs have been in existence since around 2013. Now, there have been a number of medication regimens that have come and gone. And over time, treatment has become simplified with the existence of basically two treatments that are pan-genotypic, meaning efficacious for all of the genotypes of hepatitis C, of which genotypes 1, 2, and 3 are the most common, making it also possible to skip checking genotypes for patients who this is a barrier to treatment or resource-poor settings. Treatment is much easier than the prior interferon days, consisting of one to three pills taken daily for 8 to 12 weeks. It's one pill daily for 12 weeks for cephalospinal or hepatosphere, and three pills daily for GP. Treatments are highly effective, leading to cure rates greater than 90%, as I've shown you for most patients. And the treatments are very well-tolerated. Side effects if experienced are often mild, such as fatigue and headache, and they rarely lead to discontinuations in treatment course, unlike the interferon days. Given that there are a few side effects, treatment courses are short and nearly everyone gets cured, guidelines no longer recommend or require monitoring during treatment for patients who are straightforward and don't have cirrhosis. In the old days, we used to use what was called response-driven therapy, where viral loads were measured prior to and during treatment to ensure there was a good response. But we no longer do that, as viral loads measured during treatment are not found to be ultimately predictive of cure, and treatment is so short there isn't even really time to respond. Next slide. Treatment for hepatitis C is really quite straightforward. The aspect of hepatitis C, which remains slightly more complicated, is the pretreatment assessment for patients who have screened positive for hepatitis C. First, I do want to review the hepatitis C screening guidelines that are newly recommended by the USPSTF guidelines. Whereas previously the guidelines had recommended screening individuals with risk factors and then individuals who were in the baby boomer cohort, the newest guidelines now recommend that all adults are screened at least one time with an hepatitis C antibody test, followed by a confirmatory RNA test. And those individuals who are at high risk, such as people who use drugs, should be periodically re-screened, although there isn't great data to say exactly how often, expert opinion is to re-screen those individuals annually. Next slide. So what should you do next for someone who screens positive for hepatitis C? This slide summarizes recommendations from the IDSA and ASLD guidelines, and again I would encourage you to be familiar with their website, which is frequently updated. So unfortunately, there are still pretreatment labs that are necessary, and this is often the most difficult step, particularly when treating people who inject drugs who have poor venous access. So the most essential lab to order is, of course, the hepatitis C viral load to confirm current infection, as approximately a quarter of all patients will spontaneously clear their infection and don't need treatment. Often a hepatitis C viral load will be sent reflexively by the lab for patients who are hepatitis C antibody positive. In an ideal world, I think all would be reflexively sent, so one should look for that. Other labs are needed to both screen for other infectious diseases that could complicate treatment, such as hepatitis E and HIV, and to assess whether the patient has cirrhosis. So those labs include CBC for platelets, a comprehensive metabolic panel to assess creatinine for renal function, and AST-ALT to assess for ongoing liver damage and to assess for cirrhosis. Hepatitis surface antigen is needed to establish whether a patient does not have active hepatitis B, as there is risk of hepatitis B disease flare during and after hep C treatment. And again, both HIV and hepatitis B co-infection would be scenarios that you would likely want to refer to a specialist for treatment. After ordering those labs, the key issue is establishing whether or not a patient has cirrhosis. And if they do have cirrhosis, determining whether it is mild, i.e., child's class A, or more severe, i.e., child's B or C. For patients with cirrhosis that's child's B or C class, you should also refer to a specialist. Patients with child's A can be safely treated with the medication regimens listed previously. But additionally, such patients will need to have workup for liver cancer, as I'll talk about later. How you assess for cirrhosis is based on a combination of factors, including the patient's history, what the labs show, and whether those results are consistent. And also what's available to you and what the patient is willing to undergo. The good news is that liver biopsies are a thing of the past. And so nowadays there are a number of options for staging that are all non-invasive and all recommended through the guidelines. The first is using a scoring algorithm based on platelets and AST-ALT. And so the two options there, FIB4, which includes platelets, AST-ALT, and age, or PRE, which is slightly simpler and includes AST and platelets only. In addition to these that are based on blood tests, there are additional send-out blood tests, which use biomarkers for fibrosis. And such tests, names that you might be familiar with or hear are FibroTest, FibroSur, or ActaTest. So the other non-invasive option that is not a blood test is transient elastography or FibroScan. So this is similar but not entirely the same to an ultrasound. It uses sound waves to detect liver stiffness. You may wonder, which of these tests should I order? So again, the answer really depends on a number of factors that I said earlier. For providers who do have easy access to FibroScan, this is probably the preferred method for staging. However, for most substance use treatment providers in community settings, like myself, this may require a referral and appointment, and as we know, there's a high likelihood of no-show for patients who use drugs. So really, as a provider, there needs to be an assessment of risk-benefit or a trade-off that has to be made as to whether to hold off treatment to get a more definitive diagnosis of cirrhosis and risk not seeing the patient again and missing the opportunity to treat. But there are many patients for which you would not need to order a FibroScan. So to give one example, say a patient who is a young adult in their late 20s who maybe started injecting only a few years earlier in their earlier 20s, does not have heavy alcohol use, and the Fib-4 in a pre suggests that there's no significant fibrosis and no cirrhosis. In that case, obviously, the patient does not need a FibroScan and can be treated. Next slide. So this slide reviews, again, what would be some scenarios when you would want to refer to a specialist, and they include any patients with decompensated cirrhosis, so signs of ascites, jaundice, varices, patients with liver cancer who've had transplant, patients with hepatitis B or HIV co-infection, and also patients who've had prior treatment with DAAs. I do want to point out again, for patients that you do refer, it is very important to try to engage the help of staff, such as social workers, case managers, and patient navigators to remove barriers to care, such as transportation issues, and to ensure that these patients are not lost to follow up. Next slide. So once you've completed the pre-treatment labs and cirrhosis assessment, what does treatment look like? So this slide summarizes IDSA ASLD guidelines for simplified treatment for patients without cirrhosis. The key steps are to review other medications for drug-drug interactions, update labs as needed, they should be current about within six months, and educate the patient about medications and the importance of adherence. Also not listed here, assessing what supports are needed for the patient to be successful, such as housing and access to syringe service programs, medications for opioid use disorder are critically important. Again, treatment is usually one of the two pan-genotypic pharmacotherapies listed here. And a big departure from prior guidelines is that during treatment, monitoring is not required. But it is important to offer visits to support and make sure that patients have uninterrupted access to medications, and talk about barriers, such as where to store medications to ensure they don't get lost or stolen, and to avoid incarceration, which can interrupt treatment. Next slide. Just a few caveats to what I said about not needing labs during treatment for patients who are straightforward. There are some scenarios when you would want to get labs during treatment, and that includes patients with diabetes to monitor for hypoglycemia and patients on Warfarin to monitor their INR. And this is basically because there can be recovery of liver function during treatment that can impact drug metabolism. There are rare reports of hepatitis B reactivation among people with isolated core antibody. And so you should consider monitoring AST-ALT med treatment at week four in those patients with anti-core antibody. For patients who need additional monitoring, again, using the help of various team members, such as a social worker, pharmacist, case manager can be very helpful. Next slide. So this slide summarizes key differences for treating patients who do have cirrhosis, i.e., compensated Child's A. Remember, B and C would go to a specialist. So the main difference is to order an ultrasound prior to treatment, ideally, to screen for liver cancer, and also to order genotype as, for patients with cirrhosis, genotype three actually can be slightly harder to treat. And then also to make sure that labs are current. So here you want labs that are within three months. And again, for any signs of decompensation seen on physical exam, refer to a specialist. Next slide. This slide lists some drug-drug interactions, but note that not all require discontinuation of medications. So this is where it's very convenient to have a relationship with a pharmacist so you can discuss how to manage these specific drug-drug interactions. And if you don't have a pharmacist to refer to, would refer you to the website listed at the bottom of the slide, pepdruginteractions.org, which has a checker for where you can plug in to the different drugs and see if there are interactions. Next slide. So this slide summarizes post-treatment care. The key here is to check for SVR-12, which again is definition of cure, and also for AST-ALT. So ideally, you will see that the patient's hepatitis C RNA is undetectable, which means the patient is cured. In the scenario of a patient being cured, but the AST and ALT remain elevated, you want to assess for other secondary causes, the most common these days being non-alcoholic steatohepatitis, or NASH, or fatty liver from alcohol use. You'll also want to provide counseling to ensure that patients avoid risks for reinfection. Next slide. This slide summarizes post-treatment care for patients with cirrhosis. So screening for liver cancer should be done at least every six months, and usually that is through an ultrasound. And patients should also have a one-time screening for esophageal varices with an EGD, particularly if they have signs of portal hypertension on their ultrasound. Finally, it's extremely important to screen for alcohol use and provide support for those individuals who are drinking to stop drinking. So unfortunately, for patients who already have cirrhosis, that damage is not entirely reversible, and it's critically important that they do abstain from drinking, or at least moderate their drinking as possible. Next slide. So this slide reinforces that hepatitis C reinfection may be an expected complication for providers who do treat high-risk populations. As we move to treat more and more persons who actively are using drugs and injecting drugs, preventing reinfection is really key to achieving elimination. So the key point here is to try to help patients to utilize services to prevent reinfection. So this means making sure patients have access to medications for opioid use disorder, have access to sterile syringes and needles and other injecting equipment through syringe service programs. And we need to remember to test patients so that we're aware when they become reinfected. And also, we really want to minimize the shame around reinfection and also providers' own personal sense of failure. Remember, having cases of reinfection is in a way a sign that one is treating a high-risk population that we need to treat to achieve elimination. When patients are reinfected, it's best to refer them to specialists for retreatment. And fortunately, there are options, good options for retreatment, the main one being a three-drug regimen, velpatasvir, sevastavir, and voxelapramir. So you can reassure patients when they do get reinfected that they can be cured again. Next slide. So again, this slide is just to remind folks that all adults should be screened one time and then individuals who are treated and cured should be rescreened. An expert opinion is that this should be annually. Next slide. And a quick reminder about immunizations. It's recommended that all individuals with substance use disorders get hepatitis A and B vaccination on whether or not they have hepatitis C, and periodic outbreaks of these diseases make this particularly important. And for individuals with cirrhosis, tobacco use, and or heavy alcohol use, they should also receive a pneumococcal vaccination. Next slide. So a summary of the key take-home points for this lecture. There's now a simplified pathway with limited monitoring for most patients, and adherence supports are helpful, but DAs are extremely forgiving of imperfect adherence, and most patients who are treated with DAs will be cured. The key is to check for SVR12 to make sure that they are cured. I can say as a provider who's provided this care, it is easy, fun, and extremely gratifying to cure people of this important disease. It's not often we have an opportunity to cure a chronic disease. And do you feel that this should become a routine part of primary care, especially for people with opioid use disorder, in order to achieve elimination goals? Next slide. Next slide. So here are some helpful resources for folks who wanna get started. The first, as I've mentioned earlier, are the Hep-C guidelines at hcvguidelines.org. The University of Washington also has an excellent Hepatitis C training site at hepatitisc.uw.edu. Many universities have Project ECHO affiliated with them, where you can get expert support for patients, and that operates on a case presentation basis. And at UCSF, there's actually a phone consultation line that is staffed 9 a.m. to 8 p.m. Eastern Time that anyone can call for questions. And as I mentioned earlier, there's a good website for checking for interactions for the medications, but I do encourage you to get to know your local or specialty pharmacist and have a relationship with them. Next slide. And just some tips from me for folks who might be thinking about diving into treatment. So start with one straightforward case. Don't pick a very complicated patient. Find a local expert or connect with Project ECHO. Identify a trusted pharmacist that you can ask questions to, and really decide what your scope of practice and what your comfort level is, and don't be afraid to refer patients if you feel that it's out of your scope. Next slide. So for that, thank you for listening, and I will take any questions that you might have. Thank you, Dr. Sui, for a very informative presentation which will allow us to save lives and vastly improve public health. We're gonna take a few minutes for questions from the audience. If people still want to submit questions, you can do that in the question area, but we have several questions already which we'll probably take up the remaining time. So the first question from Jeff Jaeger is, why has it been so hard to develop a vaccine for hepatitis C? Oh, that is a good question. And so I'm not an expert in vaccines, so I can't go into sort of the details from an immunologic standpoint, but I will say that there is a vaccine that has been in development, and my understanding is that it's more, it's sort of an adjunct, it's being looked at as more sort of an adjunct to prevent reinfection. So there is some work that is going on there, but unfortunately, we are not at the, you know, in the same situation with hepatitis A and B that we can prevent hepatitis C. But we are very fortunate that we do have these curative therapies available, and in theory, we can eliminate disease through these medications that we have. Thank you. So the next question comes from Kelly Barth, and the question is, if we're only checking for the hepatitis B antigen pretreatment, which would, to my understanding, indicate an active hepatitis B infection, how will we know to monitor for B reactivation for someone who has a hepatitis B antibody? In other words, the idea is they've been infected, but we think they have cured the hepatitis B virus as I understand it. So I'm kind of combining my own questions with Dr. Barth's questions, but is the question clear, Dr. Suey? Yeah, and it's a good question. It is, unfortunately, this slightly gray area remaining. So for patients who have a positive surface antigen, I mean, that's clear-cut. They have active hepatitis B. And so those folks you wanna refer to a specialist, and what's recommended is really to suppress their hepatitis B infection first with medications and then treat the hepatitis C. But for the sort of slightly gray area, for most individuals who have been exposed to hepatitis B, ideally, you would see surface antibodies and core antibodies. And for those who received vaccine, they will have surface antibodies. Unfortunately, what we do sometimes see is that there are individuals who are core antibody positive only. And for the most part, that usually reflects somebody who has been exposed a long time ago and they no longer have detectable surface antibody, and they only have core antibody, and they don't have active infection. But there is this phenomenon of, it's been referred to as occult hepatitis B. So there's very small numbers of individuals may actually have active viral infection. So if you check their hepatitis B DNA, it will be positive. And again, this is referred to as occult hep B, and it's usually in the case of somebody who's core antibody positive only. But this is extremely rare, but there is this concern that for those folks treating hepatitis C, they could have a flare. And for that reason, some providers will choose for individuals who are hep B core antibody positive only to check AST, ALT during treatment, usually week four, and just make sure that there's not a flare going on. Thank you. The next question, and then we'll have to wrap up with the questions, how to screen patients for reinfection after they've been treated? Because they will still have, obviously, that hep C antibody present. Right, really good question, really important question. So they have to be screened with a viral load, which is obviously more costly, but that is the only way that we will detect a new infection, a reinfection. Okay, thank you, Dr. Tsui. And thank you all for participating in today's session. Next slide. Please visit www.pcssnow.org and see the variety of helpful resources that are offered, including the free PCSS Mentor Program, which offers general information to clinicians about evidence-based clinical practices in prescribing medications for opioid use disorder. PCSS mentors have expertise in medication for substance use treatment and clinical education. You can also find the PCSS discussion forum, a simple and direct way to receive an answer related to medication for substance use treatment. Today's activity was presented on behalf of the SAMHSA funded Providers Clinical Support System, a program operated collaboratively by 19 medical specialty organizations, including the American Psychiatric Association. Again, thank you for joining us today. We hope to see you soon. Goodbye, everyone.

hepatitis C

treating hepatitis C

people who use drugs

healthcare professionals

myths about treating hepatitis C

treatment guidelines

direct acting antiviral medications

cure rates

pre-treatment assessments